Quality Improvement Plan (QIP)
Narrative for Health Care Organizations in Ontario
April 3, 2024
OVERVIEW
Derbecker’s Heritage House is an independently owned 72 bed Long Term Care Home that is situated in the picturesque village of St. Jacobs, with a 58 year history of providing the highest standard of Resident Centered Care by a committed team. This commitment is central to our Mission, Vision and Values and is guided by continued quality improvement that measurably improves resident centered care.
Our focus is to continue to maintain and improve the high standard of care we have always seen at Derbecker’s Heritage House. Our main goals are to ensure that we provide individualized care, a home like environment and atmosphere, support residents, families and our own staff while meeting all of the legislative requirements of the Fixing Long Term Care Act 2021. Many changes took place during 2023. Changes to the management team, new external business partnerships were established and a process to implement new policies, processes and assessments was initiated.
Sprinkler system was installed along with air conditioning in all resident rooms and central areas. Upgrades to décor and resident washrooms were started and are underway in 2024.
The following is an overview and outcome of Derbecker’s Heritage House identified priority area identified in our 2023/2024 Quality Improvement Plan.
Outcome of 2023/2024 Quality Improvement Plan:
Number of residents taking an antipsychotic medication without a diagnosis of psychosis.
Performance 2023/2024 – 17.78%
Target – 17.60%
Change Idea #1 – 100% of residents receiving anti-psychotic medication will have a medication review completed quarterly for intent and effectiveness Date implemented March 2023.
To identify this year’s priority areas for the quality improvement plan, we took into consideration the benchmarked performance of indicators specific to the Home and CIHI indicators identifying the high-risk areas, the results of our Resident, Family Experience Survey, other performance measures such as audits, evaluations,best practice. Priority areas are based on these and the recommendations by the Continuous Quality Improvement Committee following a review of the home’s quality performance measures from the previous year during the committee meetings.
ACCESS AND FLOW
Our trained clinical staff work with community partners such as the Nurse Led Outreach Team, Behaviour Support Ontario Psychogeriatric Resource consultants, Community Geriatricians and Hospice to ensure that we are optimizing support and care in the home. We use quality indicator results such as emergency room transfers to monitor our performance within the Long-Term care sector. Upgrades and changes to clinical software enable timely access to consults and lab results as examples. New initiatives are underway to interface with local hospitals to enhance communication during resident transfers. The main goal being to provide the right care, at the right time.
EQUITY AND INDIGENOUS HEALTH
When developing a Health Equity Plan our home examined the culture and diversity of the people we serve. By creating an understanding and respect of the cultural diversity, we can provide care that appreciates the differences and values of our residents, staff and families.
PATIENT/CLIENT/RESIDENT EXPERIENCE
Client engagement and experiences have always been a priority at Derbecker’s Heritage House.
We now have dedicated Social Work hours. The Social Work presence is a definite asset to the home. Our current Social Worker provides support and resources to our Residents, Families and Staff.
We conducted our annual Resident, Family, and Caregiver experience survey December 2023. The outcome of the survey was as follows:
Eleven main areas were surveyed, examples are meals, housekeeping, quality of life, staffing. Our home exceeded scores from the previous year in all areas but one. Data from Quality Council is shared with residents, families and staff to ensure the whole home is involved in initiatives and changes.
We will continue to strive and uphold our current and previous history of resident satisfaction.
PROVIDER EXPERIENCE
We have a team of committed, caring staff who have always provided and continue to provide exemplary care under ever changing circumstances. Staff retention and recruitment are a priority and to demonstrate this Heritage House has many staff who have worked in the home for well over a decade. We continue to actively recruit new staff in all departments and agency staff are used only in extreme situations.
Supporting current staff with internal, external education and opportunities to grow within are available and encouraged. Several PSW staff are trained preceptors, which enables us to enhance the student placement experience. While partnering with Humber College, we are proud of the three staff who successfully completed the certified PSW course 2023/2024.
During 2023 an external consulting company was used to provide support and grief counselling for staff.
SAFETY
Resident and staff safety are a priority, our policies and processes are aligned with legislative requirements. We strive to create an environment free of safety risks for all of our stakeholders, regularly and proactively analyzing and anticipating risks, working hard to prevent them from occurring. Our primary approach is creating a Safety Culture – one that acknowledges that everyone has a role to play in safety prevention and to understand system vulnerabilities so we can further reduce opportunities for unexpected safety issues.
POPULATION HEALTH APPROACH
Prevention in this area is extremely important. Ensuring that a culture of education and information are present while at the same time supporting the resident right to choose. Vaccination clinics, infection prevention and control policies and processes offer residents, families and staff, up to date information and service. Access to and creating strong relationships with external partners enable the home to stay current with ever changing best practices and strides forward in care of the elderly. The Nurse Led Outreach Team and Hospice allow residents to be diagnosed and receive care at the home thus avoiding hospital transfers. Collaboration with RNAO NQuire program for assessment, early detection and response in areas such as delirium and pain ensure resident care it timely and focused. Taking advantage of initiatives such as “diagnostic equipment funding” allow homes to purchase much needed equipment for early detection and diagnosis.
CONTACT INFORMATION/DESIGNATED LEAD
Licensee/delegate – Pamela Derbecker
Administrator /Executive Director – Pamela Derbecker
Quality Committee Chair/delegate – Paula Leland